Provider Demographics
NPI:1073246146
Name:BERGLUND, SAMANTHA JOYCE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOYCE
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24953 PASEO DE VALENCIA
Mailing Address - Street 2:BLDG B, STE. 1B
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-540-0170
Mailing Address - Fax:949-540-0173
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:BLDG B, STE. 1B
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-540-0170
Practice Address - Fax:949-540-0173
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)